The Common Clinical Competency Framework for Non-medical Ophthalmic Healthcare Professionals in Secondary Care

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Daniel White
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1 The Common Clinical Competency Framework for Non-medical Ophthalmic Healthcare Professionals in Secondary Care Medical Retina November 2016 Association of Health Professions in Ophthalmology

2 General basic competences of non-medical eye health care professionals The basic skill set of an ophthalmic non-medical health care professional (qualified optometrist, orthoptist, ophthalmic nurse or ophthalmic clinical scientist) is to: Perform basic clinical ophthalmic assessment Follow protocols within their scope of practice under appropriate supervision Detect abnormalities through assessment and act on these findings Not make a diagnosis or treat This level of skills and competences is essential before undertaking further training and education for a Level 1 expanded role; and some HCPs may need additional ophthalmic training (basic ophthalmic training courses) to obtain these skills. Possession of a competence indicates demonstration of an understanding of the underlying principles, limitations and benefits of the skill, as well as being able to elicit the appropriate information accurately. History taking Basic science knowledge about symptomatology of eye disease Communication skills ability to elicit relevant information Clinical knowledge about ophthalmic presentations Ability to take a general ophthalmic history Ability to take a social, family and drug history Ability to take a relevant systemic history, including past medical history Ophthalmic examination Ophthalmic basic science knowledge - Anatomy - Physiology - Pathology - Optics - Microbiology Understanding of basic disease processes Ability to elicit and recognise the relevance of positive and negative findings on examination Visual acuity measurement understanding of various methods and notations External ocular examination Slit lamp examination Fundal examination Pupil reactions Eye movements Clinical assessment of visual fields Understand management of refractive error Investigations Recognise roles of various investigations and understand their basis Dealing with the needs of ophthalmic patients Understand the terminology and notation used for ophthalmic examinations including refractive status Communication skills - patients, relatives and colleagues - written, oral and non verbal Time management skills Patient as the focus of care Patient safety Infection control including equipment decontamination Knowledge of and adherence to local policies Team working Epidemiology of ophthalmic disease Understand basic drug principles Instil drops Administer drugs as prescribed Recognise allergies and common complications Teaching and education Recognise own development needs Ability to share basic information with patients for their education and understanding Personal development Self-learning Reflective practice Recognise and develop evidence based practice Recognise limitations of own practice and competences and works within this scope CPD identify channels through which skills can be maintained and developed 2

3 Competence in practice Medical Retina Relevant underlying knowledge in competence and behavioural skills. Level 1 Level 2 Level 3 Participate in screening, under supervision, of medical retina (MR) patients and participate in monitoring low risk patients with established diagnoses in protocol driven treatment clinics Participate in triage and assessment of new patients. Perform assessment, management and monitoring under specific protocols Participate in hospital based medical retina (MR) patient care, managing and discharging patients under the care of a consultant ophthalmologist Ophthalmic history taking An ability to Take a comprehensive history relevant to the patient with a medical retinal (MR) condition with particular emphasis on relevant past medical, ophthalmic and drug history Recognise specific systemic conditions of relevance to medical retinal (MR) diseases Elicit specific information in the differential diagnosis of MR and how the history may be helpful in determining the different conditions Recognise history relevant to systemic conditions which may affect medical retina treatment outcomes and refer to ophthalmologists as appropriate 3

4 Ophthalmic examination As per general competences Understand the anatomy, physiology and pathophysiology of the retina, with emphasis on the macula Understand and recognise the risk factors and differential diagnosis of disorders of retinal and macular pathology including : - AMD dry, and wet (neovascular) - Central retinal vein occlusion (CRVO) / branch retinal vein occlusion (BRVO) - Diabetic retinopathy / maculopathy - Cystoid macular oedema (CMO) - Central serous retinopathy (CSR) - Other differential diagnoses Detect and classify diabetic retinal disease Detect the features needed to accurately grade diabetic retinopathy Recognise and understand the relevance of anterior segment changes associated with medical retinal disease eg APD, rubeosis, anterior chamber activity Undertake a competent ophthalmic examination with regard to medical retinal disorders Use a 3 mirror fundus contact lens as indicated and interpret the results Detect the features needed to accurately grade diabetic retinopathy according to modified Early Treatment Diabetic Retinopathy Study (ETDRS) criteria including pre-proliferative retinopathy, diabetic maculopathy and PDR with high risk characteristics Investigations Perform OCT imaging and fundus photography Recognise basic pathology on OCT images and fundus photographs Understand diabetes, diabetic eye disease and its relevance to retinopathy screening Recognise the use of fluorescein and ICG angiography, and autofluorescence in medical retina service delivery Use and interpret of ICG Use and interpret OCT imaging software and fundus photographs to review data and make accurate diagnosis Select and interpret need for specific tests for medical retina conditions Recognise and use electrodiagnostics Recognise and use ultrasound 4

5 Investigations continued Understand the principles of fluorescein, ICG angiography and autofluorescence in medical retina service delivery Detect the features needed to accurately grade diabetic retinopathy Select and interpret need for specific tests for medical retina conditions Interpret fluorescein, ICG angiography and autofluorescence in medical retina service delivery Management and interventions Recognise acute retinal pathology, conduct appropriate tests and make appropriate referrals, clearly stating the level of urgency Recognise current national referral guidelines and detailed knowledge of local referral pathways for patients with medical retina disorders Understand the principles, processes and protocols of national diabetic retinopathy screening programmes Make re-treat decisions for namd within own level of competence, according to local protocols in a consultant ophthalmologist-led pathway, including the ability to determine when to seek further advice Recognise a disease course that is unusual Communicate with colleagues within a multidisciplinary setting Diagnose neovascular AMD (namd) with a provisional recommendation for treatment Differentially diagnose retinal and macular conditions and manage or refer as appropriate Make re-treat decisions for namd according to local protocols in a consultant ophthalmologist led pathway, including the ability to determine when further investigations are required in the event of atypical or suboptimal responses to treatment Monitor the response to treatment and modify management plan of referred patients Recognise risks and benefits of medical, laser and surgical interventions for different treatments for medical retina conditions Administer pharmacological interventions, including intravitreal injections in line with local policy and guidelines Integrate clinical data in order to make differential diagnoses, and instigate appropriate management plans according to protocol and supervision as required 5

6 Ability to deal with needs of ophthalmic patients Communicate to patients information about their diagnosis and potential management options including referral to rehabilitation services and eligibility for registration Provide information and psychological support for the patient and carers Recognise the risks for patients about the natural history of the condition and any therapeutic interventions Work in a team and communicate with relevant members Be aware of the rapidly evolving nature of medical retina treatments that may be requested by patients Be part of the consent pathway Communicate with patients about their diagnosis, treatment plans and outcomes Manage patients fears and concerns Understand pharmacology of anti-vegf medications, to include possible contraindications, side effects and drug interactions Administer pharmacological interventions in line with local policy and guidelines Teaching and education Inform and educate patients and carers regarding medical retina disorders and their management Inform/educate patients the reasons behind monitoring plan Teach and train other groups of professions 6

7 Personal development Direct self-learning Understand reflective practice Recognise the need to work within own level of competence Seek advice where appropriate Demonstrate participation in CPD Work within the clinical governance framework service Recognise NICE guidelines and local protocols for AMD, diabetic macular oedema (DMO) and RVOs Keep up to date with, apply and act upon the NICE guidelines and local protocols for AMD, diabetic macular oedema (DMO) and RVOs as part of the team Recognise clinical trials which may influence current and future practice Audit own and service activity Non-medical eye HPCs who participate in medical retina pathways must possess basic science knowledge of the epidemiology, clinical features, natural history and possible progression of the various types of disease. They will be familiar with evidence based guidelines and have a knowledge of basic principles and limitations of relevant equipment and tests along with the technical skills to employ it effectively. The Level 1 competences are in keeping with the Professional Certificate in medical retina currently available from the University of Cardiff, City University of London and Ulster University. 7

8 Abbreviations AMD Age Related Macular Degeneration ICG Indocyanine Green APD Afferent Pupillary Defect IOP Intra Ocular Pressure BRVO Branch Retinal Vein Occlusion IP Independent Prescriber CMO Cystoid Macular Oedema LA/GA Local Anaesthetic/General Anaesthetic COAG Chronic Open Angle Glaucoma MR Medical Retina CPD CRVO CSR DM DMO DR HCPs HEIs Continuing Professional Development Central Retinal Vein Occlusion Central Serous Retinopathy Diabetes Mellitus Diabetic Macular Oedema Diabetic Retinopathy Health Care Professionals Higher Education Institutions namd OCT OHT PGD PI RVO SLT Neovascular Age Related Macular Degeneration (wet AMD) Optical Coherence Tomography Ocular Hypertension Patient Group Directive Peripheal Iridotomy Retinal Vein Occlusion Selective Laser Trabeculoplasty HES Hospital Eye Service Contact Professor Caroline MacEwen President The Royal College of Ophthalmologists 18 Stephenson Way London NW1 2HD T E.

The Common Clinical Competency Framework for Non-medical Ophthalmic Healthcare Professionals in Secondary Care

The Common Clinical Competency Framework for Non-medical Ophthalmic Healthcare Professionals in Secondary Care Cataract November 2016 Association of Health Professions in Ophthalmology General basic competences